| (j) Annual provision of preferred provider listing
required in certain cases. If no preferred provider website listing
or other method of identifying current preferred providers is maintained
for use by insureds, the insurer must distribute a current preferred
provider listing to all insureds no less than annually by mail, or
by an alternative method of delivery if an alternative method is agreed
to by the insured, group policyholder on behalf of the group, or certificate
holder.
(k) Reliance on preferred provider listing in certain
cases. A claim for services rendered by a nonpreferred provider must
be paid in the same manner as if no preferred provider had been available
under §3.3708(a)(5) of this title (relating to Payment of Certain
Out-of-Network Claims), and the insurer must take responsibility for
any balance bill amount the nonpreferred provider may charge in excess
of the insurer's payment if an insured demonstrates that:
(1) in obtaining services, the insured reasonably relied
upon a statement that a physician or provider was a preferred provider
as specified in:
(A) a preferred provider listing; or
(B) preferred provider information on the insurer's
website;
(2) the preferred provider listing or website information
was obtained from the insurer, the insurer's website, or the website
of a third party designated by the insurer to provide such information
for use by its insureds;
(3) the preferred provider listing or website information
was obtained not more than 30 days prior to the date of services;
and
(4) the preferred provider listing or website information
obtained indicates that the provider is a preferred provider within
the insurer's network.
(l) Additional listing-specific disclosure requirements.
In all preferred provider listings, including any website postings
by the insurer to insureds about preferred providers, the insurer
must comply with the requirements in paragraphs (1) - (11) of this
subsection.
(1) The preferred provider information must include
a method for insureds to identify those hospitals that have contractually
agreed with the insurer to facilitate the usage of preferred providers
as specified in subparagraphs (A) and (B) of this paragraph.
(A) The hospital will exercise good-faith efforts to
accommodate requests from insureds to utilize preferred providers.
(B) In those instances in which a particular facility-based
physician or provider or physician group is assigned at least 48 hours
prior to services being rendered, the hospital will provide the insured
with information that is:
(i) furnished at least 24 hours prior to services being
rendered; and
(ii) sufficient to enable the insured to identify the
physician or physician group with enough specificity to permit the
insured to determine, along with preferred provider listings made
available by the insurer, whether the assigned facility-based physician
or provider or physician group is a preferred provider.
(2) The preferred provider information must include
a method for insureds to identify, for each preferred provider hospital,
the percentage of the total dollar amount of claims filed with the
insurer by or on behalf of facility-based physicians that are not
under contract with the insurer. The information must be available
by class of facility-based physician, including radiologists, anesthesiologists,
pathologists, emergency department physicians, and neonatologists.
(3) In determining the percentages specified in paragraph
(2) of this subsection, an insurer may consider claims filed in a
12-month period designated by the insurer ending not more than 12
months before the date the information specified in paragraph (2)
of this subsection is provided to the insured.
(4) The preferred provider information must indicate
whether each preferred provider is accepting new patients.
(5) The preferred provider information must provide
a method by which insureds may notify the insurer of inaccurate information
in the listing, with specific reference to:
(A) information about the provider's contract status;
and
(B) whether the provider is accepting new patients.
(6) The preferred provider information must provide
a method by which insureds may identify preferred provider facility-based
physicians or providers able to provide services at preferred provider
facilities, if applicable.
(7) The preferred provider information must be provided
in at least 10-point type.
(8) The preferred provider information must specifically
identify those facilities at which the insurer has no contracts with
a class of facility-based provider, specifying the applicable provider
class.
(9) The preferred provider information must be dated.
(10) Consistent with Insurance Code Chapter 1451, Subchapter
K, concerning Health Care Provider Directories, for each health care
provider that is a facility included in the listing, the insurer must:
(A) create separate headings under the facility name
for radiologists, anesthesiologists, anesthesiologist assistants,
nurse anesthetists, nurse midwives, pathologists, emergency department
physicians, neonatologists, physical therapists, occupational therapists,
speech-language pathologists, and surgical assistants, except that
a physician or health care provider who is employed by the facility
is not required to be listed;
(B) under each heading described by subparagraph (A)
of this paragraph, list each preferred facility-based physician or
provider practicing in the specialty corresponding with that heading;
(C) for the facility and each facility-based physician
or provider described by subparagraph (B) of this paragraph, clearly
indicate each health benefit plan issued by the insurer that may provide
coverage for the services provided by that facility, physician or
provider, or facility-based physician or provider group;
(D) for each facility-based physician or provider described
by subparagraph (B) of this paragraph, include the name, street address,
telephone number, and any physician or provider group in which the
facility-based physician or provider practices; and
(E) include the facility in a listing of all facilities
and indicate:
(i) the name of the facility;
(ii) the municipality in which the facility is located
or county in which the facility is located if the facility is in the
unincorporated area of the county; and
(iii) each health benefit plan issued by the insurer
that may provide coverage for the services provided by the facility.
(11) Consistent with Insurance Code Chapter 1451, Subchapter
K, the listing must list each facility-based physician or provider
individually and, if a physician or provider belongs to a physician
or provider group, also as part of the physician or provider group.
(m) Annual policyholder notice concerning use of an
access plan. An insurer operating a preferred provider benefit plan
that relies on an access plan as specified in §3.3707 of this
title (relating to Waiver Due to Failure to Contract in Local Markets)
must provide notice of this fact to each individual and group policyholder
participating in the plan at policy issuance and at least 30 days
prior to renewal of an existing policy. The notice must include:
(1) a link to any webpage listing of information on
network waivers and access plans disclosed under subsection (d)(2)
of this section and made available under subsection (e) of this section;
(2) information on how to obtain or view any access
plan or plans the insurer uses; and
(3) a link to the department's website where the department
posts information relevant to the grant of waivers.
(n) Disclosure of substantial decrease in the availability
of certain preferred providers. An insurer is required to provide
notice as specified in this subsection of a substantial decrease in
the availability of preferred facility-based physicians or providers
at a preferred provider facility.
(1) A decrease is substantial if:
(A) the contract between the insurer and any facility-based
physician or provider group that comprises 75% or more of the preferred
providers for that specialty at the facility terminates; or
(B) the contract between the facility and any facility-based
physician or provider group that comprises 75% or more of the preferred
providers for that specialty at the facility terminates, and the insurer
receives notice as required under §3.3703(a)(26) of this title
(relating to Contracting Requirements).
(2) For purposes of this subsection, decreases in numbers
of physicians and other providers must be assessed separately, but
no notice of a substantial decrease is required if the requirements
specified in either subparagraph (A) or (B) of this paragraph are
met:
Cont'd... |
